What are the 5 main steps to confirming a death?
1. Confirm patient identity, 2. Check for response to stimuli, 3. Check pupillary responses, 4. Feel the carotid pulse, 5. Auscultate for heart and lung sounds
If after a fluid status examination a patient is found to be hypovolaemic, what should you do?
Initiate fluid resuscitation
What are some clinical signs of a patient being fluid overloaded?
Raised JVP, peripheral/sacral/pulmonary oedema
What should be done next if an individual's blood glucose has been > 14mmol/L for more than 2 hours?
Check blood ketones
Excessive amounts of IV 0.9% sodium chloride can result in what metabolic abnormality?
Hyperchloraemic metabolic acidosis
How can you calculate what one unit of insulin will reduce an individual's blood glucose by?
100 / total daily dose
In any patient with a reduced urine output (< 0.5ml/kg/hour), a fluid challenge should be given. What is meant by this?
250-500ml of 0.9% sodium chloride or Hartmann's solution over 15 minutes
What are some further investigations you may consider doing after a fluid status examination?
Bloods (Hb, U&Es, renal function), imaging (CXR, ECHO, abdominal US)
The main advantage of 5% dextrose is being able to maintain hydration without administering an excess of electrolytes. However, if required it can be prescribed with supplementary amounts of what electrolyte?
Describe the main components of the general examination section of a fluid status examination?
End of the bed assessment (SOB, oedema, medical equipment), hands (CRT, skin turgor), pulse and BP, neck (JVP), eyes and mouth (dry mucous membranes), legs (oedema)
How are maintenance fluids calculated for children?
100ml/kg for first 10kg, 50ml/kg for the next 10kg, 20ml/kg for any additional kg
What medication should you be aware of that increases fluid losses?
If after a fluid status examination a patient is found to be euvolaemic, what should you do?
Calculate maintenance fluids (if required)
How should you check for a response to stimuli when confirming death?
1. Assess for a verbal response, introduce yourself and ask the patient if they can hear you, 2. Assess for a response to pain by applying supraorbital pressure
What are the 2 main reasons that somebody may become hypervolaemic?
Increased fluid intake, fluid retention (e.g. cardiac/renal failure)
How is the fluid within the extracellular space divided into compartments?
1/4 is found in the intravascular space (plasma) while 3/4 are found in the extravascular space (interstitial fluid)
What is the correction dose of insulin for people who remain hyperglycaemic (BM 10-15mmol/L) despite their normal subcutaneous insulin? (assuming they haven't just eaten and have taken a bolus)
10% of total daily dose
What is the daily requirement of water?
What should you do if a patient appears euvolaemic but has signs of shock?
Seek expert help immediately
What electrolytes are found in 1L of 0.9% sodium chloride?
154mmol of sodium and chloride
What electrolytes are found in 1L of Hartmann's solution?
131mmol sodium, 111mmol chloride, 5mmol potassium, 2mmol calcium and 29mmol bicarbonate
If after a fluid status examination a patient is found to be hypervolaemic, what should you do?
Do not prescribe IV fluids and seek senior help
What are you hoping to achieve when giving a fluid challenge?
Increase in BP and decrease in HR
What electrolyte can be added to 0.9% sodium chloride if required?
Potassium (as 20 or 40mmol KCl)
What is the daily requirement of sodium, potassium and chloride?
1-2mmol/kg/day for sodium, 1mmol/kg/day for potassium and chloride
What is most people's baseline rate of insulin, e.g. a sensible dose to start someone on who is first diagnosed with type 1 diabetes?
How many units of insulin are in 1ml?
What is the correction dose of insulin for people who remain hyperglycaemic (BM > 15mmol/L) despite their normal subcutaneous insulin? (assuming they haven't just eaten and have taken a bolus)
20% of total daily dose
Fluid losses from non-urine sources are termed insensible losses- these will increase in who?
Acutely unwell patients
What are the most important questions to ask yourself before prescribing any fluids?
What type of fluid prescribing is required? What is the weight and size of the patient? Are there any co-morbidities to consider? What are their most recent electrolytes?